OKOJ, Volume 5, No. 6

A scaphoid nonunion occurs in untreated scaphoid fractures and in scaphoid fractures that fail to show signs of healing after 3 months of cast treatment. Initial scaphoid fractures usually occur as isolated injuries, but they can occur in combination with other extremity injuries that mask the pain and swelling at the wrist. Diagnosis of scaphoid nonunion is based on patient history, physical examination, and imaging studies. The standard of treatment consists of internal fixation and bone grafting the scaphoid. This article reviews the pathophysiology and clinical presentation of scaphoid nonunion and reviews the considerations in surgical management. Specific surgical techniques reviewed in detail include palmar approach, dorsal approach, and vascularized bone graft.

Osteosarcoma is the most commonly isolated malignant bone tumor in children, followed by Ewing's sarcoma and lymphoma. Classic osteosarcoma is the most common subtype of osteosarcoma. Lesions usually occur in the metaphyses of long bones, most frequently in the distal femur, proximal tibia, proximal humerus, and proximal femur, in that order. Treatment for osteosarcoma includes preoperative chemotherapy, wide surgical resection, and postoperative chemotherapy. Lymphoma of bone is a rare malignant tumor that originates from lymphoblastic tissue. Primary lymphomas are most common in the metaphyses of the major long and flat bones. Chemotherapy is the primary treatment modality. Radiation therapy is sometimes used, particularly when there is inadequate response to chemotherapy. Ewing's sarcoma is a highly malignant neoplasm that affects the long bones of the skeleton (femur, tibia, and humerus), as well as the spine, pelvis, and ribs. Standard treatment for Ewing's sarcoma is chemotherapy. Following a satisfactory response to chemotherapy, patients are evaluated to determine whether surgery, radiation therapy, or both are the best modalities to control the disease.

The value of total elbow arthroplasty is best demonstrated in patients with rheumatoid arthritis. Dr. Morrey performs an elbow joint replacement in a 51-year old woman with a very severe form of rheumatoid arthritis involving all of her joints. At the elbow, the destruction is so extensive as to closely resemble what is termed mutilans—that is, complete alteration of the arm architecture. This particular patient's presentation is also associated with a severe flexion deformity, which is a major problem for her because she has severe wrist pathology as well. The goals of the surgery include relieving the patient of her pain and to release the elbow and to resolve as much as possible the approximate 45° to 50° flexion contracture. Dr. Morrey demonstrates his surgical approach and shows how to perform ulnar nerve dissection and lateral dissection, establish the humeral and ulnar canals, perform radial head resection, cement the implant components, and perform elbow closure.

Although the outcomes of single-bundle anterior cruciate ligament (ACL) reconstruction have been favorable, multiple authors have noted persistent instability and residual pain in a subset of patients following this surgery. Consequently, interest has increased in the use of double-bundle ACL reconstruction to provide a better restoration of knee anatomy, kinematics, and biomechanics. Recent biomechanical studies have suggested that double-bundle ACL reconstruction may provide better anteroposterior and rotational stability than single-bundle reconstruction. Short-term results have been favorable; however, long-term clinical studies are needed to determine whether double-bundle ACL reconstruction results in improved patient outcomes compared with single-bundle techniques.

Chondromalacia patella is a softening and degeneration of the articular cartilage of the patellofemoral joint as a result of overuse, injury, or abnormal joint mechanics. The condition is a common source of anterior knee pain. Most patients with chondromalacia patella may be treated nonsurgically. Surgical treatment includes lateral retinacular release when there is lateral facet softening as a result of chronic patellar tilt; proximal reconstruction of the medial patellofemoral ligament and tibial tubercle transfer to stabilize the extensor mechanism in patients with recurrent instability; anteromedial tibial tubercle transfer for patients in whom a distal articular cartilage lesion is a chronic source of pain; and articular resurfacing, when a rebalancing procedure fails to remove stress from a deficient and/or painful patellofemoral joint surface. In some patients, a combination of procedures may be most appropriate.

Keywords:

runners knee

anterior knee pain

patellofemoral joint pain

kneecap pain

patellofemoral dysfunction

patellofemoral syndrome

patellofemoral pain syndrome

Subspecialty:

Sports Medicine

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